Can nurses accept gifts from patients?

That covers the small gift card tucked into a thank-you card for the nurses who were there every night. Children's Mercy, a US hospital, works through nearly that exact case in its own gift policy: a mother gives two staff members $20 gift certificates to the local restaurant where she works, thanking them for fitting her child into a clinic appointment so quickly. The answer is no, because staff there "may never accept cash, cash equivalents (including Gift cards or Gift certificates)" from patients or their families.

Cash and gift cards are out "regardless of the dollar amount" at Mount Sinai South Nassau, a New York hospital. At Harris Health in Texas, staff may not accept "cash or cash equivalent items (e.g. gift cards) from patients." In NHS hospitals in England, cash and vouchers get a single line from NHS England:

gifts of cash and vouchers should always be declined.

Two rules that leave a gift card a little room

A gift card gets a softer answer from one nursing regulator we read, the College of Nurses of Ontario, which takes the case of a patient who overhears that it is a nurse's birthday and offers a local restaurant's gift card. "Generally, nurses should avoid accepting gifts from clients," the College answers, though "In limited circumstances, accepting a gift may be appropriate," mainly where refusing could hurt the relationship or seem disrespectful. Even then, the value has to be modest, and before any yes a nurse there must "consult with their employer or follow organizational policies," which hands the decision back to the employer's own rule.

If the nurse works for the VA

Even the one rule we read whose dollar limit a store gift card can fit under comes with advice to turn it down. It is federal ethics law, which binds a nurse who works for the VA, and its own worked example lets a federal employee keep a $15 store gift card "as the market value is less than $20," but not a card issued by a credit card company or other financial institution, which "is equivalent to a gift of cash"; the $20 exception "does not apply to gifts of cash" at all. Gifts from veterans are covered, as the Boise VA Medical Center's compliance officer tells its staff. "Every VA employee must comply with federal laws" on using office for private gain, and a federal employee generally may not take a gift from a "prohibited source," which "includes veterans." The same officer's bottom line for VA staff:

it is always safer to decline a gift that is offered to you because you work at the VA.

Why nurses can't accept just any gift from patients

Turning down the gift card is not turning down the thanks. NHS staff "may sometimes receive gifts as a legitimate expression of gratitude," NHS England's rule says. The worry is how a gift can look. A nurse in the UK has to "refuse all but the most trivial gifts, favours or hospitality," because accepting them "could be interpreted as an attempt to gain preferential treatment," as the Nursing and Midwifery Council's Code puts it.

Seen from the bed, the rule protects the patient: patients "should never form the impression that their care is dependent upon gifts or donations of any kind," according to the Nursing Council of New Zealand. Families are inside the rule too: under the same UK Code, nurses keep "clear professional boundaries" with the people in their care, "their families and carers."

What to give the nurses instead

Where these rules say yes, they are warier of a present for one nurse than of something the whole ward can share. Token gifts like chocolates or flowers are where New Zealand's nursing regulator generally draws the line, and a gift to the group is more acceptable there "as any provision of good care is by the whole team rather than an individual nurse." Small things meant for sharing can pass; larger items, or items of value, do not.

Modest gifts, or perishable ones like food or flowers, are accepted at Children's Mercy only when they are shared with everyone in the department, and a discharged patient's batch of Christmas cookies, left in the break room for all the staff, is the policy's own example. Food and flowers pass at Harris Health on the same condition, shared with the department or unit, and so does one more kind of gift: something the patient made, such as a knitted scarf, a tote bag or a wood carving, worth less than $50. Any other object from a patient is "strongly discouraged" there.

At the VA, the card you write in falls outside the federal rule altogether: its definition of a gift leaves out "Greeting cards," along with "Modest items of food and non-alcoholic refreshments, such as soft drinks, coffee, and donuts, offered other than as part of a meal."

The line, rule by rule

How much is too much depends on whose rule it is.

• At Mount Sinai South Nassau, flowers, cookies or candy are acceptable with "a fair market value of less than $50 per item, per individual, not to exceed $100 per year."
• At Children's Mercy, a "Modest" gift is one "of moderate or low value (usually less than $35)."
• Under the federal rule, a nurse who works for the VA may accept an unsolicited gift of "$20 or less per source per occasion," and no more than $50 in a calendar year from any one person.

In England's NHS hospitals the line is drawn in pounds: "modest gifts under a value of £50 do not need to be declared," while gifts "valued at over £50" can be accepted only on behalf of the hospital, into its charitable funds, never by the nurse personally. A family's gifts add up, too. Several from the same giver within 12 months are treated like a single gift over the line "where the cumulative value exceeds £50," under NHS England's rule, and any NHS hospital may set a stricter rule of its own.

Where a bigger thank-you goes

A bigger thank-you than that has a route of its own. A family wishing to donate money to Children's Mercy is sent to its Philanthropy department. Under New Zealand's guidance, cash is never accepted by the nurse, but it can go to a charity, or into a fund that buys things for other patients or for the staff as a group, where the hospital's policy allows it.

Flowers are the token most of these rules name, and the ward has its own say on them: do hospitals allow flowers?